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Whitepapers, briefs, press releases and more

CMS Section 1115 Budget Neutrality Review: What States Need to Prepare Now

What states and actuaries should know about CMS’s emerging budget neutrality certification process. CMS is moving toward a more detailed, activity-level review of Section 1115 budget neutrality. States may need to distinguish MAPS activities from Section 1115-only activities and provide stronger actuarial support for projected costs, savings, utilization changes, assumptions, and uncertainty. Who should read ... Continue reading

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Week in Washington 09/10/26

CMS Continues DME Anti-Fraud Push CMS announced it would block 11 medical supply companies from receiving payments under Medicare Advantage or Part D. The firms were involved in $3.4 billion in suspected fraudulent billing practices in 2025 and 2026. The focus on DME billing practices is expected to continue. MA actuaries may need to reassess ... Continue reading

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Newsworthy Findings

Mass General Brigham Health Plan Drops MA Coverage For Dana-Farber Patients

Mass General Brigham Health Plan has announced that it is eliminating the Dana-Farber Cancer Institute from its Medicare Advantage network Oct. 1. The insurer said it’s dropping coverage due to the challenging environment affecting Medicare Advantage plans nationwide.

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Editor's Note
The change won’t affect commercial products, and the cancer institute will still be a part of the Mass General Brigham Health Plan commercial provider network.

Medicare Spent Hundreds of Millions of Dollars on Ineligible Drugs, Audit Finds

Medicare spent more than half a billion dollars over three years on drugs it shouldn’t have paid for.

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Editor's Note
The HHS Office of the Inspector General audited Medicare’s Part D prescription drug benefit and found it spent $587.7 million from 2021 through 2023 on five drugs that were labeled prescription-only, despite the Food and Drug administration switching them to over the counter more than a year prior. Part D does not cover drugs that can be purchased over the counter.

Top Democrat Investigates No Surprises Arbiters

Rep. Frank Pallone sent oversight letters to six arbiters, requesting information on how they decide awards, how they’re paid and more. His office is also in communication with other arbiters.

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Editor's Note
The No Surprises Act’s IDR process has expanded significantly, with 2.5 million disputes filed in 2025 and 1.4 million in the first five months of 2026, compared with an initial estimate of about 17,000 disputes per year. Rep. Frank Pallone is seeking information from six IDR entities about their dispute decisions and processes, as some entities have reported provider win rates above 90%. A recent study also estimated the process resulted in more than $22 billion in additional healthcare spending during the first four years of its implementation.

HHS Announces $383.4M In Behavioral Health, Crisis Response Services Grants

The U.S. Department of Health and Human Services (HHS) awarded more than $383 million in grants Tuesday to strengthen the nation’s behavioral health treatment, prevention and crisis response services.

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Editor's Note
The HHS awarded $383.4 million in grants to strengthen behavioral health treatment, prevention, and crisis-response services, with $252 million directed toward the 988 Suicide & Crisis Lifeline, suicide prevention, and mobile crisis services. The funding also includes $81.4 million for substance use treatment and prevention and $50 million for mental health initiatives.

CMS Puts More Pressure on DME Suppliers as Part of Anti-Fraud Push

CMS added 11 durable medical equipment (DME) suppliers to its Preclusion List after identifying more than $3.4 billion in suspected fraudulent billing activity, including claims for deceased beneficiaries and equipment that was never requested or received.

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Editor's Note
CMS's latest enforcement actions highlight the agency's increasing reliance on data analytics and targeted oversight to combat healthcare fraud and protect Medicare program.

Bonus Article

Just for Fun

Math Riddle:

Why do mathematicians never argue with circles?

Prior Week

Q: Using only addition, how can you make 1,000 from eight 8s?

A: 888 + 88 + 8 + 8 + 8 = 1,000

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